The stress and distress of infertility

114 Pages·2006·0English

The stress and distress of infertility: Does spirituality help
women cope?

Alice D. Domar, PhD, Alan Penzias, MD, Jeffery A. Dusek, PhD,
Amora Magna, BA, Dalia Merarim, PhD, Barbara Nielsen, MDiv, PhD,
Debika Paul, BA

In this evaluation of nearly 200 infertile women, high levels of
religiosity and spirituality are significantly correlated with low levels of
psychological distress. Clinicians should be prepared to discuss
religious and spiritual issues with their patients, as those issues may
play an important role in the psychological health of infertile women—
and in their response to infertility treatment.
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A Randomized Study Evaluating Acupuncture
as an Adjunct to IVF
Source: Rodolfo Quintero, M.D., Wendy Yu, L.Ac., Brandon Horn,
L.Ac., J.D., Daoshing Ni, D.O.M., Barry Schifrin, MD., Brian Acacio,
M.D.
Department of Obstetrics and Gynecology, Glendale Adventist Medical
Center (GAMC) and the Eastern Center for Complementary Medicine,
Glendale, CA
A Randomized Study Evaluating Acupuncture as an Adjunct to IVF
Acupuncture is based on patterns of energy flow (Qi) through a
network of meridians. Maintenance of Qi is essential for health, while
blockage may provoke disease. Acupuncture works by unblocking the
various types of stagnation that can occur along these channels. After
Paulus et. al demonstrated the benefit of acupuncture to IVF (Fertil
Steril Apr 2002),
many IVF centers began offering these services.
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Reduction of blood flow impedance in the uterine arteries of
infertile women with electro-acupuncture
Source: European Society for Human Reproduction and
EmbryologySource: European Society for Human Reproduction and
Embryology
In order to assess whether electro-acupuncture (EA) can reduce a high
uterine artery blood flow inpedance, 10 infertile but otherwise healthy
women with a pulsatility index...
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Acupuncture Normalizes Dysfunction of Hypothalamic-
Pituitary-Ovarian Axis

Bo-Ying Chen M.D.
Professor of Neurobiology
This article summarizes the studies of the mechanism of
electroacupuncture (EA) in the regulation of the abnormal function of
hypothalamic pituitary-ovarian...
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Acupuncture Treatment For Infertile Women Undergoing
Intracytoplasmic Sperm Injection
Sandra L. Emmons, MD
Phillip Patton, MD
Infertility is an area of women's health that has sparked much
consumer interest in acupuncture. However, there is little published
information concerning the combination of...
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Effects of Electro-Acupuncture on Nerve Growth Factor and
Ovarian Morphology in Rats with Experimentally Induced
Polycystic Ovaries
Elisabet Stener-Victorin,[2,3] Thomas Lundeberg,[4] Urban
Waldenström,[3] Luigi Manni,[5] Luigi Aloe,[5] Stefan Gunnarsson,[6]
and Per Olof Janson[3]
Despite extensive research on the pathogenesis of polycystic ovary
syndrome (PCOS), there is still disagreement on the underlying
mechanisms. The rat model for experimentally...
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Substitution of Acupuncture for HCG in Ovulation Induction
Cai Xuefen
Obstetrical & Gynecological Hospital,
Zhejiang Medical University, Zhejiang Province 310006
By using human menopausal gonadotropin (HMG) and human
chorionic gonadotropin (HCG), fairly good clinical therapeutic efficacy
has been obtained in the treatment of infertility...
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Relationship Between Blood Radioimmunoreactive Beta-
Endorphin and Hand Skin Temperature During The Electro-
Acupuncture Induction of Ovulation

Chen Bo Ying M.D. Lecturer of Neurobiology
Institute of Acupuncture Research,
and
Yu Jin, MD., Prof of Gynecology
Obstetricus and Gynecology Hospital
Shanghai Medical University
Shanghai, People's Republic of China
Thirteen cycles of anovulation menstruation in 11 cases were treated
with Electro-Acupuncture (EA) ovulation induction. In 6 of these
cycles...
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Influence of acupuncture on the pregnancy rate in patients who
undergo assisted reproduction therapy
Wolfgang E. Paulus, M.D.,[a] Mingmin Zhang, M.D.,[b] Erwin Strehler,
M.D.,[a]
Imam El-Danasouri, Ph.D.,[a] and Karl Sterzik, M.D.[a]
Acupuncture is an important element of traditional Chinese medicine
(TCM), which can be traced back for at least 4,000 years.
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Role of acupuncture in the treatment of female infertility
By
Raymond Chang, M.D.[a,b] Pak H. Chung, M.D.[b] and Zev
Rosenwaks, M.D.[c]
Although the understanding of acupuncture is based on ancient
medical theory, studies have suggested that certain effects of...
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Clinical Studies of Chiropractic during Pregnancy

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Clinical Studies of Acupunture for Fertility and Pregnancy
Acupuncture has numerous potential fertility-boosting benefits
according to New York Weill Cornell physician-scientists
http://www.news.cornell.edu/releases/April03/fertility.html
New York, NY (April 29, 2003)--Physician-scientists at the Center for
Reproductive Medicine and Infertility (CRMI) at New York Weill Cornell
medical center call for a definitive study of acupuncture as a fertility
treatment, citing its numerous, promising benefits associated with
increasing fertility in women. .An article in a recent issue of Fertility
and Sterility--co-authored by Dr. Zev Rosenwaks, Dr. Pak H. Chung,
and Dr. Raymond Chang of Weill Cornell--provides a summary of
current research that supports acupunctures potential benefits for
fertility treatment, including the stimulation of increased uterine blood
flow and fertility hormones.
"Acupuncture, which is nontoxic and relatively affordable, holds much
promise as a complementary or alternative fertility treatment," said
Dr. Raymond Chang of New York Weill Cornell Medical Center. "Yet,
while there are a great number of biological explanations for
acupunctures benefits to fertility, as well as significant anecdotal
evidence, there has yet to be a definitive clinical study," added Dr.
Rosenwaks, Director of CRMI.
"One of the biggest obstacles to any study of acupuncture is a single
standard of care," said Dr. Pak H. Chung of New York Weill Cornell
Medical Center. "Only appropriate training and certification of
acupuncture practitioners by state agencies can facilitate the
integration of acupuncture into the treatment of female infertility, and
health care in general."
The lead review article reports that acupuncture treatment has the
following potential fertility-boosting benefits:
(cid:31) Increased blood flow to the uterus and therefore uterine wall
thickness, an important marker for fertility
(cid:31) Increased endorphin production, which, in turn, has been
shown to effect the release of a gonadotropin-releasing hormone
(GnRH), a decapeptide involved in regulating reproduction
(cid:31) Lower stress hormones responsible for infertility
(cid:31) Impact on plasma levels of the fertility hormones: follicle-
stimulating hormone (FSH), luteinizing hormone (LH), estradiol
(E2), and Progesterone (P)
(cid:31) Normalization of the hypothalamic-pituitary-ovarian axis, a
key process in fertility
(cid:31) A positive effect for women with polycystic ovarian
syndrome, a hormonal imbalance present in three percent of
adolescents and adults.
Acupuncture is the manipulation of thin metallic needles inserted into
anatomically defined locations on the body to affect bodily function.
These so-called acupoints correspond to areas on the surface of the
body that have been shown to have greater electrical conductance due
to the presence of a higher density of gap junctions along cell borders.
A greater metabolic rate, temperature, and calcium ion concentration
are also observed at these points.
Dr. Rosenwaks, Director of the Center for Reproductive Medicine and
Infertility, and Dr. Chung treat infertility patients at Weill Cornell
Medical Center at New York-Presbyterian Hospital. Dr. Rosenwaks is
the Revlon Professor of Reproductive Medicine in Obstetrics and
Gynecology, Co-Director of the Institute for Reproductive Medicine,
and Attending Obstetrician and Gynecologist at Weill Cornell. Dr.
Chung is Assistant Professor of Reproductive Medicine, Assistant
Professor of Obstetrics and Gynecology, and Assistant Attending
Obstetrician and Gynecologist at Weill Cornell. Dr. Chang is Clinical
Assistant Professor of Medicine at Weill Cornell, where he teaches
courses on alternative and complementary medicine. He is also
affiliated with Meridian Medical.
The stress and distress of infertility: Does spirituality help
women cope?

Alice D. Domar, PhD, Alan Penzias, MD, Jeffery A. Dusek, PhD,
Amora Magna, BA, Dalia Merarim, PhD, Barbara Nielsen, MDiv, PhD,
Debika Paul, BA

In this evaluation of nearly 200 infertile women, high levels of
religiosity and spirituality are significantly correlated with low levels of
psychological distress. Clinicians should be prepared to discuss
religious and spiritual issues with their patients, as those issues may
play an important role in the psychological health of infertile women—
and in their response to infertility treatment.

Key Points
Women who experience infertility are more likely to suffer from
heightened depression and anxiety symptoms than women in general.
The longer the infertility and the greater the associated distress, the
more likely a patient will suffer depressive symptoms, which can in
turn diminish fertility and interfere with treatment success.
A high level of spiritual well-being is significantly linked with less
infertility distress and fewer depressive symptoms, suggesting a
relationship between spirituality and the psychological well-being of
women undergoing infertility treatment. Conversely, self-reported
depressive symptoms and lower levels of spiritual well-being predict
higher levels of infertility distress.
Spirituality and religion are important sources of solace for most
individuals. Many physicians do not describe themselves as personally
religious, and most are not trained to discuss spiritual matters with
patients. However, physicians may be well-advised to inquire about
and support patients' religious beliefs to help promote their physical
and psychological well-being.
Patients with strong religious faith, studies show, sustain medical
crises with better outcomes than those who do not hold strong
spiritual beliefs or maintain religious practices.1 Research also shows
that religious people tend to have a greater sense of well-being,
greater life satisfaction, lower levels of depression and anxiety, and a
decreased risk of suicide.2–7
Society, especially religious society, has traditionally valued woman for
her life-giving role. So it is not surprising that living with unrealized
hopes for a child can negatively affect a woman's psychological well-
being.

Infertility and depression
Women who experience infertility report significantly higher levels of
depressive symptoms8 and anxiety9 than women in the fertile
population. In one study, 11% of infertile subjects met the criteria for
a major depressive episode, compared to 3.6% of fertile subjects.10
In another study of infertile women, half of the subjects reported
changes in their sexual function, and 75% reported changes in mood,
such as increased feelings of sadness.9
There is also evidence that depressive symptoms are associated with
decreased fertility and can interfere with the success of infertility
treatment. In one investigation, women with a lifetime history of
clinical depression were nearly twice as likely to report infertility as
those not depressed.11In vitro fertilization (IVF) patients who reported
heightened levels of depressive symptoms prior to beginning IVF
treatment had significantly lower success rates than women with lower
levels of depressive symptoms.12,13 In general, infertility-related
stress has been found to have direct and indirect adverse effects on
treatment outcomes.14
In caring for the infertile woman, then, it is important to identify and
minimize factors that lead to depressive symptoms and psychological
distress and to identify and emphasize factors that are associated with
healthy coping. If, for example, religious women were to report lower
levels of depressive symptoms or psychological distress during
infertility than less religious women, health care professionals might
want to encourage their patients to consider religious or spiritual
practices that have provided comfort in the past.
One study was located which considered the relationship between faith
and fertility, and it only assessed Jewish women in Israel. Women
undergoing IVF were asked to indicate their attitude toward religion
and to classify themselves as secular, traditional, or orthodox.15 The
study uncovered a significant relationship between religious
observance and conception rates, with the highest rates in the
traditional group. Of those who conceived, 70% classified themselves
as “traditional.” Among the women who didn't conceive, only 27%
reported traditional religious practice. Folkman and Chesney suggest
that “reliance on spiritual beliefs and engaging in spiritual activity have
been identified as ways of coping in stressful situations.”16 Adherence
to traditional faith may provide an effective way to cope with adversity
and disappointment.

Religion's advantages— and possible drawbacks
Strong religious beliefs may help or interfere with coping and healing.
On the one hand, some may find comfort by believing that infertility is
part of a divine plan, while others may interpret infertility as
punishment from a higher power for past sins and indiscretions. Some
infertile women who display strong religious or spiritual beliefs may
achieve relaxation through prayer. Others may experience heightened
levels of distress from feeling that their prayers for a child have gone
unanswered, or from agonizing over whether to pursue a treatment
that may be specifically banned by their religion.
Being religious may benefit the infertility patient by providing a feeling
of community and reducing social isolation. Conversely, a religious
perspective may heighten a woman's sense of social isolation from a
religious community that emphasizes childbearing. Infertile couples
may be stigmatized by religious doctrines that make parenthood a
core identity, such as the Old Testament commandment to “be fruitful
and multiply” (Genesis 1:28). Thus, religious beliefs may actually
compound the negative psychological effects of infertility.17

An investigation
In order to explore these connections in further detail, the authors
conducted a study to investigate the role of religiosity and/or
spirituality in shaping the subjective psychological well-being of
infertile women. The 3 specific questions addressed in this research
were:
(1) Is there a relationship between spirituality (either religious well-
being or existential well-being) and depressive symptoms?

(2) Is there an association between increased spirituality and
decreased infertility distress? and

(3) Do women who report more depressive symptoms also report
more distress with their infertility?

Materials and methods
Subjects
Those eligible to participate included all English-speaking women who
had a scheduled appointment or procedure at any of the 4 offices of
Boston IVF, a hospital-affiliated infertility practice, during the
recruitment phase (March 1 through August 1, 2000).
Materials
Each participant was asked to complete 4 questionnaires while waiting
for an appointment with an infertility specialist. The questionnaires
included:
• the Beck Depression Inventory,18 which measures depression
severity and is a widely-used self-report instrument for assessing
depression

• the Fertility Problem Inventory,19 which measures perceived
infertility-related stress and identifies and measures domains of stress
specific to infertility such as social, sexual, and relationship concerns

• the Spiritual Well-Being Scale,20 evaluating the quality of one's
spiritual health in a 2-dimensional construct: religious well-being and
existential well-being, and

• a demographic form, collecting information on religious
denomination, current religious practices, infertility history, and mental
health history.
The Spiritual Well-Being Scale was developed to measure the quality
of spiritual health. It has two constructs—religious well-being (well-